CMS-10668 CMS Hospital-Acquired Condition (HAC) Reduction Program

CMS Hospital-Acquired Condition (HAC) Reduction Program Validation Review for Reconsideration Request

If the Centers for Medicare & Medicaid Services (CMS) determines that a hospital did not meet the Hospital-Acquired Condition (HAC) Reduction
Program data validation requirement due to a confidence interval validation score of less than 75 percent and the hospital would like to request a
reconsideration, the hospital must complete and submit this form. Hospitals are not required to resubmit a copy of a medical record that was
previously sent to the Clinical Data Abstraction Center (CDAC) Contractor. Note: CMS limits the scope of data validation reconsideration reviews to
information already submitted by the hospital during the initial validation process, and we will not abstract medical records that were not submitted to
the CMS contractor during the initial validation process. We will expand the scope of our review only if we find during the review that the hospital
correctly and timely submitted the requested medical records.
This form and medical record(s) (if applicable) must be received by the Validation Support Contractor, by the deadline identified on the HAC
Reduction Program Validation Notification Letter. Hospitals must send the form/medical record(s) to the “Validation Support Contractor” group via
the CMS Managed File Transfer (MFT) application: https://qnetmft.cms.gov/. This form cannot be sent via regular email. Contact
[email protected] for questions/assistance.
Following the receipt of the request form/medical records, an email acknowledgement will be sent confirming the form has been received. Once a
determination has been made, CMS will provide the formal decision regarding the reconsideration request.
Fields marked with (*) indicates required field

*Facility Information:
*CMS Certification Number (CCN):

*Hospital Name:

*Designated Personnel Contact Information:
*Name and Title:
*Email Address:
*Telephone Number:

Ext.

*Mailing Address (must include physical address; P.O. Box addresses are not valid):

*City:
*State:
April 2024

*ZIP Code:

CMS Hospital-Acquired Condition (HAC) Reduction Program Validation Review for Reconsideration Request

*Validation Review for Reconsideration Request Form:
Fields marked with (†) can be found on the Case Detail Report.
If you need to request reconsideration for more elements, or if additional space is needed to describe the rationale, you may attach another document to accompany this
form.
Rationale*: Please provide written justification in the space below for each appealed data
Data
NHSN element classified as a mismatch. Mismatched data elements that affect a hospital’s validation
Patient
Abstraction
Discharge
Quarter*†
Element
ID*†
Control #*†
Date*†
Event ID score would be subject to reconsideration. Supplemental information that was not located in the
Name*†
original medical record sent to the CDAC cannot be accepted. If the rationale field is blank, the
form will not be accepted.

April 2024

CMS Hospital-Acquired Condition (HAC) Reduction Program Validation Review for Reconsideration Request
Patient
ID*†

April 2024

Abstraction
Control #*†

Quarter*†

Discharge
Date*†

Data
Element
Name*†

Rationale*: Please provide written justification in the space below for each appealed data
NHSN element classified as a mismatch. Mismatched data elements that affect a hospital’s validation
Event ID score would be subject to reconsideration. Supplemental information that was not located in the

original medical record sent to the CDAC cannot be accepted. If the rationale field is blank, the
form will not be accepted.

CMS Hospital-Acquired Condition (HAC) Reduction Program Validation Review for Reconsideration Request
Patient
ID*†

April 2024

Abstraction
Control #*†

Quarter*†

Discharge
Date*†

Data
Element
Name*†

Rationale*: Please provide written justification in the space below for each appealed data
NHSN element classified as a mismatch. Mismatched data elements that affect a hospital’s validation
Event ID score would be subject to reconsideration. Supplemental information that was not located in the

original medical record sent to the CDAC cannot be accepted. If the rationale field is blank, the
form will not be accepted.

CMS Hospital-Acquired Condition (HAC) Reduction Program Validation Review for Reconsideration Request
Patient
ID*†

Abstraction
Control #*†

Quarter*†

Discharge
Date*†

Data
Element
Name*†

Rationale*: Please provide written justification in the space below for each appealed data
NHSN element classified as a mismatch. Mismatched data elements that affect a hospital’s validation
Event ID score would be subject to reconsideration. Supplemental information that was not located in the

original medical record sent to the CDAC cannot be accepted. If the rationale field is blank, the
form will not be accepted.

PRA Disclosure Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-1352 (Expires 11/30/2025). The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, MD 21244-1850. ****CMS Disclosure**** Please
do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence
not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions
or concerns regarding where to submit your documents, please contact the Validation Support Contractor at [email protected].

April 2024